Improving Care, Delivering Quality … · Improving Care, Delivering Quality Reducing mortality & harm in Cardiff & Vale University Health Board National Learning Session - 10th June

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Improving Care, Delivering QualityReducing mortality & harm in

Cardiff & Vale University Health Board

National Learning Session - 10th June 2011

Driver Diagram

Reduce

Mortality,

Harm,

Variation

and

Waste

Ventilator bundle

Hospital Acquired

Infections

Central & Peripheral Line Insertion &

Maintenance Bundles

Blood stream infections

Clostridium Dificile Bundle

VTEs HAT assessment, prevention and

treatment

Clostridium Dificile

Surgical Errors WHO Checklist

Surgical site infections

Ventilator acquired Pneumonias

Catheter Associated UTI

Stroke care

Leadership for QI

WalkRounds/Patient Safety Fridays

Medicines Management

Reconciliation

High risk medications

Transforming Care

Heart Failure

SKIN Bundle

Falls Prevention

Mental Health

Sepsis/RRAILS

Mortality & Harm Reviews

First episode psychosis

Depression

Dementia

Early Warning Scores & Rapid

ResponseSSI Bundle

Urine Catheter insertion &

maintenance bundles

Pressure Ulcers

Pathways and Bundles

Build Skills Capacity & Capability

Risk Adjusted Mortality Index (RAMI)

0

20

40

60

80

100

120

140

Ja

n-

09

Fe

b-

09

M

ar-

09

Ap

r-

09

M

ay-

09

Ju

n-

09

J

ul-

09

Au

g-

09

Se

p-

09

Oc

t-

09

No

v-

09

De

c-

09

Ja

n-

10

Fe

b-

10

M

ar-

10

Ap

r-

10

M

ay-

10

Ju

n-

10

J

ul-

10

Au

g-

10

Se

p-

10

Oc

t-

10

No

v-

10

Month

RA

MI

C&V

All Welsh Average

Risk Adjusted Mortality Index

(RAMI)

Mortality as % FECMortality as % of FCE

0

0.5

1

1.5

2

2.5

3

3.5

Ja

n-

09

Fe

b-

09

M

ar-

09

Ap

r-

09

M

ay-

09

Ju

n-

09

J

ul-

09

Au

g-

09

Se

p-

09

Oc

t-

09

No

v-

09

De

c-

09

Ja

n-

10

Fe

b-

10

M

ar-

10

Ap

r-

10

M

ay-

10

Ju

n-

10

J

ul-

10

Au

g-

10

Se

p-

10

Oc

t-

10

No

v-

10

Month

%

C&V

All Welsh Average

RAMI

• Weekly Deaths Review Group established

– Led by Medical Director, supported by Assistant Medical Directors

(x2); Assistant Director Patient Safety & Quality; Improvement Advisor

and Clinical Coding Manager, Clinical Coder in rotation to inform

learning

• Data extracts generated weekly via Clinical Governance

Data Analyst from CHKS, patients whose RAMI suggests

least likely to die (RAMI less than 0.25)

RAMI

• On average 18 of 45 weekly deaths case notes reviewed

• If triggers identified Medical Director generates letter for lead

Consultant to undertake case review and feedback

• Key learning to date

– Coding Quality improving

– Raising the profile and importance of clinical coding with clinicians

and making some operational changes to working arrangements to

strengthen coder / clinician interface.

Monthly Conversion rate

Cardiff and Vale University Health Board - UHW

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

Jul-0

6

Oct

-06

Jan-

07

Apr

-07

Jul-0

7

Oct

-07

Jan-

08

Apr

-08

Jul-0

8

Oct

-08

Jan-

09

Apr

-09

Jul-0

9

Oct

-09

Jan-

10

Apr

-10

Perc

en

tag

e

Values Average (17.6)

Monthly Conversion rate

Cardiff and Vale University Health Board - UHL

0.0

5.0

10.0

15.0

20.0

25.0

Oct

-07

Dec

-07

Feb-

08

Apr

-08

Jun-

08

Aug

-08

Oct

-08

Dec

-08

Feb-

09

Apr

-09

Jun-

09

Aug

-09

Oct

-09

Dec

-09

Feb-

10

Apr

-10

Perc

en

tag

e


Number of triggers


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Jul-0

6

Oct

-06

Jan-

07

Apr

-07

Jul-0

7

Oct

-07

Jan-

08

Apr

-08

Jul-0

8

Oct

-08

Jan-

09

Apr

-09

Jul-0

9

Oct

-09

Jan-

10

Apr

-10

Nu

mb

er


Number of triggers


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Oct

-07

Dec

-07

Feb-

08

Apr

-08

Jun-

08

Aug

-08

Oct

-08

Dec

-08

Feb-

09

Apr

-09

Jun-

09

Aug

-09

Oct

-09

Dec

-09

Feb-

10

Apr

-10

Nu

mb

er


13 consecutive data points under

mean = statistical significance.

Trigger Conversion Rates

% Conversion rate

is double at UHW

Adverse event rate per 1000 patient days


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Jul-0

6

Oct

-06

Jan-

07

Apr

-07

Jul-0

7

Oct

-07

Jan-

08

Apr

-08

Jul-0

8

Oct

-08

Jan-

09

Apr

-09

Jul-0

9

Oct

-09

Jan-

10

Apr

-10

Rate


Global Trigger Tool -

UHW Events by trigger code

Cardiff and Vale University Health Board - UHW from Jul 06 to

May 10

0

5

10

15

20

25

30

35

L12

G7

G3

G4

G2

G1

S1 L8 L13

L10

S2 L3 L14 L4 G

6G

5 L1 L2 L6 L7 M2

M4

S3 I2 L5 L11

M1

M5

Trigger code

Nu

mb

er

L12 Wound Infection

G7 Complication of

procedure or treatment

Adverse event rate per 1000 patient days


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Oct-0

7

Dec

-07

Feb-0

8

Apr-0

8

Jun-

08

Aug-0

8

Oct-0

8

Dec

-08

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-0

9

Dec

-09

Feb-1

0

Apr-1

0

Rate


Events by trigger code

Cardiff and Vale University Health Board - UHL from Oct 07 to

May 10

0

5

10

15

20

25

30

35

40

45

G7

G3

G4

L12

G2

L10

L13

G1

G6

S1 S2 L2 L3 M2 L1 G

8 L5 L6 L8 M1

M5

Trigger code

Nu

mb

er

G7 Complications of

procedure or treatment

Global Trigger Tool -

UHL

Learning from GTT

• Similar event rates at both main sites

• More triggers at UHL than UHW average 40: 29

• Increase in triggers is due to increase in general care triggers detected at UHW

• Conversion rate is double at UHW that of UHL (18:9)

• L12 (wound infection) is the highest trigger at UHW

• G7 (complication of treatment) is the highest trigger at UHL

Next steps for harm and

mortality

• Better analysis of the data – identify learning points –

• Gain greater understanding of RAMI

• Triangulate learning from GTT, mortality reviews,

compliments, complaints and claims

• Learn from staff Culture Survey

• Prioritise actions

Leadership - WalkRounds

Patient Safety Fridays commenced in November 2009

• Two different WalkRounds take place every Friday, each attended by one Executive Director and one Independent Member, joined by a note taker to record discussions

• All sites and departments across Cardiff and the Vale are visited

• Focus on UHB organisational priorities, including hand hygiene, falls prevention, pressure sores and Transforming Care programme.

• Database used to log actions raised and share with divisional teams and executive

• Recurring themes are staffing and estates/environments of care issues

Leadership - WalkRounds

Next steps

• Develop relationships with Estates to agree and monitor actions

• Maintain focus on Q&S organisational priorities

• Outcomes reported and scrutinised at board and Quality and Safety

Committee

Where have WalkRounds taken place?UHW

UHL

Whitchurch

St David's

Rookw ood

Barry Hospital

Health Centres & Clinics

Mental Health Services

Lansdow ne

West Wing

HMP Cardiff

Nursing Homes

Schools

Independent Member Ivar Grey visited the Community Dental Service in Park

View Health Centre in March 2011 to discuss patient safety concerns with

Rhiannon Harber, Community Dental Officer, and Phillippa Scattergood,

Community Dental Nurse.

Which divisions have the WalkRounds visited?

Children & Women

Clinical Diagnostics

Dental

Medicine

Mental Health

PCIC

Specialist Services

Surgical Services

Other

Capacity and Capability

• Leading to Deliver programme for all Directorate teams

• Establishing a „Faculty‟

• Model for Improvement incorporated in other programmes e.g. Care to Lead for ward sisters, Transforming Care, SKIN Bundle roll out and through attendance at 1000 Lives Plus learning events.

Stroke

% compliance with First Hours bundle

Stroke patients

from May 2010 to May 2011

0

10

20

30

40

50

60

70

80

90

100

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011

May

2011Months

% compliance with First Days bundle

Stroke patients


0

10

20

30

40

50

60

70

80

90

100

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011

May

2011Months

• The biggest single issue of non-compliance was in respect of

patients being transferred to the acute stroke unit within 24

hours.

Stroke

% compliance with First 3 Days bundle

Stroke patients


0

10

20

30

40

50

60

70

80

90

100

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011

May

2011Months

% compliance with First 7 Days bundle

Stroke patients


0

10

20

30

40

50

60

70

80

90

100

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011

May

2011Months

• Plan - bring together all stroke rehabilitation services at Llandough and Cardiff Royal Infirmary West Wing under one roof to improve care for patients and support for families.

Stroke cont…

• Data suggests that the bundles are having a significant positive impact on improved mortality, reduced morbidity and improved length of stay but it is too early to be conclusive. A supportive discharge model is proposed to facilitate a more timely discharge to continue rehabilitation in primary care which is currently being discussed.

HCAIs – Clostridium-difficile• Key interventions to achieve this included

• Clostridium Difficile strategic and operational groups to take work forward

• The launch of the infection prevention and control policy

• Clostridium Difficile Divisional action plans

• Measuring and process improvement on:– Hand hygiene compliance and bare below the elbow

– Ward cleaning scores

– Measuring Days between C-dif events on wards – undertaking Root Cause Analysis (RCA) investigations on all reported events

– Commode cleaning, bed stripping and cleaning

– Antibiotic policy – restriction and monitoring of cephalosporin prescribing.

Indwelling catheter bundles

• Insertion and maintenance bundles are being tested and implemented for the following:

• CVC

• PVC

• Urine Catheters

The Bundle…

• The bundle that we will be piloting on A7 will look like this…

INSERTION Mark insertion

site

MAINTENANCE

Days 1 2 3 4

R/V

5

R/V

Date of insertion: VIP Score:

Remove if 2

or above

Reason for insertion:

IVAbx (I),

Blood (B),

IV Fluids (F)

Other (O)

Cannula still

required?

Yes/No

Aseptic Insertion:

Hand hygiene, PPE,

skin prep, dressing

Yes/No

Dressing

clean and

intact?

Yes/No

Lot No: PVC

procedures

performed

aseptically

Yes/NoSize/Colour:

Inserted by:

Contact No.

Comments:

Removed by:

Response –

Insertion

Bundle

NPSA Alert to raise

awareness of incidentsEvidence

based

components

of care

Traceability elements

Insert

catheter

sticky here!

What happened on

insertion?

Guidance on appropriate

catheter choice

Long/Short term

Response –

Maintenance

BundlePrompts staff to find out

patients catheter history

e.g. date of insertion,

•date due for change/removal

The six

evidence

based

components

of care

Indicates what to do every 7

days, e.g. new paperwork,

change bag/valve OR change

the catheter

Additional

removal

prompt

Compliance is audited by number of √‟s (Yes), demonstrating staff have given the

required standard of care.

Urine Catheter Bundles

Pilot ward C7% compliance with insertion bundle by week

C7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

28/11

/10

05/12

/10

12/12

/10

19/12

/10

26/12

/10

02/01

/11

09/01

/11

16/01

/11

23/01

/11

30/01

/11

06/02

/11

13/02

/11

20/02

/11

27/02

/11

06/03

/11

13/03

/11

20/03

/11

27/03

/11

03/04

/11

10/04

/11

17/04

/11

24/04

/11

% c

om

pli

an

ce

% compliance w ith insertion bundle

% compliance with maintenance bundle by week

C7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

28/11

/10

05/12

/10

12/12

/10

19/12

/10

26/12

/10

02/01

/11

09/01

/11

16/01

/11

23/01

/11

30/01

/11

06/02

/11

13/02

/11

20/02

/11

27/02

/11

06/03

/11

13/03

/11

20/03

/11

27/03

/11

03/04

/11

10/04

/11

17/04

/11

24/04

/11

% c

om

pli

an

ce

% compliance w ith maintenance bundle

Next steps

• Ensure reliability is established on pilot

sites

• Spread to other areas on the back of

Transforming Care/SKIN Bundle

Safer Surgery

Compliance with WHO / NPSA Surgical Checklist


0%

20%

40%

60%

80%

100%

120%

Jul 2010 Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

ComplianceAverage (89%)Lower limit 68%)Upper limit 100%)

Compliance with peri-operative normothermia


0%

20%

40%

60%

80%

100%

120%

Jul 2010 Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

ComplianceAverage (79%)Lower limit 56%)Upper limit 100%)

Depression

• The depression work stream aims to identify and treat patients in general hospital care with depression. We are now in the process of testing this as a pilot in the pain clinic. HADS will be used alongside the recommended PHQ9 as a screening tool.

• Main issue is going to be the uploading information on the database.

Dementia & Medicines

Management• In the UHB work has begun to develop a new pathway to

include appropriate levels of assessment, planning and discharge in a general hospital setting for patients who are cognitively impaired.

• The Medicines management work stream is dovetailed with mental health and focusing on prescribing anti-psychotic drugs for dementia.

First Episode Psychosis

Key interventions will include:

• Access to NICE recommended psychosocial interventions for

people with FEP and their families

• Timely & appropriate management of FEP

• Increase functioning / social recovery

• Increased user/carer engagement & satisfaction

First Episode Psychosis

• A baseline of time of untreated psychosis is being established by reviewing all new referrals to the community mental health teams from April – September 2010 (number = 2612) to identify people with possible psychosis. Care coordinators were contacted and teams interviewed for people who had psychosis. Information was triangulated to calculate the length of untreated psychosis.

• Next steps include reviewing baseline data, attending the second national learning event in June and agreeing priorities for action.

Falls Prevention

• Cardiff East Locality Team (CELT) are a multi agency locality

team who work from a central office in the heart of the

community. Their patient group is adults 18 and up.

Cardiff East Locality Team aim to have:

• 80% compliance with screening tool

• 80% compliance with multi-factorial risk assessment

• 80% compliance with plan by 6/52

• Improvement in standardised documentation for falls patients

Changes:

• Consent forms show that all patients have agreed to participate in the programme

• Unified Baseline Assessment completed on 100% of patients

• CELT is trial-blazing the University Health Board‟s approach to falls

RESULTS

• Significant achievement for CELT: no re-referrals for falls

• Consistent follow-up of patients

• On-going review and development of documentation in progress

• 73% of patients referred to CELT for Falls Prevention received

a full assessment.(27% declined or were admitted to hospital

etc)

% patients who complete the initial

screening using an agreed tool

Falls

from Aug 2010 to Feb 2011

0

50

100

150

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Months

% patients who have their fall logged on

central falls register

Falls


0

50

100

150

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Months

RESULTS continued

% patients who complete a basic falls risk

assessment using an agreed risk

assessment tool

Falls


0

50

100

150

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Months

% patients who receive the full Assessment

Bundle

Falls


050

100150

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Months

% patients who have falls history taken

Falls


0204060

80100120

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Months

% patients who are provided written and

oral information about falls prevention.

Falls


020406080

100120

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Months

Lessons learned

As depicted in the graphs we are now complying at 100% due to :-

Implementing and evolving the paperwork used to collect data via feedback from the team.

Through the use of PDSA cycles we developed documentation for the assessment bundle that is the most efficient for our team.

Identified need for staff training during the implementation of paperwork which subsequently led to increased compliance with assessment completion.

Continual auditing of assessment completion to ensure all falls patients receive an equitable service.

The collection and inputting of information on to the database needs to be shared within the team due to the possibility of work pressures, sickness and leave.

Next Steps CELT involved with and informing the EU – Primary Care

Pathway – assessment and intervention of fallers and

means to communicate from EU – Primary Care

Monitoring bundle – to demonstrate compliance and if any

repeat falls

Transforming Care

• Three of the wards within the Trauma and Orthopaedic Directorate have taken part in the Transforming Care programme: B6 UHW and West 3 & West 5 UHL

AIMS

• Increase the amount of time in direct care to 70%

• To reduce adverse events by 50%

• Increase patient satisfaction to at least 95%

• Increase staff satisfaction to at least 95%

Impact

• Following the themes of the programme all wards have made significant savings in both finances and time

• £800 saved after medicines cupboards were re organised and unwanted and unused stock returned

Value Added Care

• All Wards taking part in the Trauma and Orthopaedic Directorate have increased direct care time to over 70% from the baseline of 40%

• Time spent communicating with patients has also increased significantly

Safety and Reliability

• Safety culture created on all wards, over 95% compliance with

daily safety briefings on all wards

• Hand Hygiene- good levels maintained

• Falls- reduced number of Falls by intentional rounding and real

time documentation

• Pressure Ulcers- all three wards have gone over 200 days

without a ward acquired pressure ulcer!

Patient Centred Care

• Ticket Home, reducing length of stay

• Patient satisfaction surveys, results displayed monthly

• Real time documentation

Reducing Pressure Damage

• 18 clinical teams completed the mini collaborative – all are using safety cross to measure days between events.

• Most teams are seeing an increase in „days between‟ pressure damage (all grades)

• Grade 3 & 4

• The bed selection decision tree has been simplified leading to more appropriate selection and use of cheaper beds.

• Standardising the use of a barrier cream and providing training to ensure the appropriate quantity is used each time resulting in less waste.

% Compliance with use of the SKIN bundle on A4

0%

20%

40%

60%

80%

100%

120%

23.12.10

13.1.11

10.2.11

18.2.11

24.2.11

3.3.11

15.3.11

24.3.11

8.4.11

Date

% Compliance with

SKIN bundle

Target 95%

A4 Pressure Ulcer

Cardiff and Vale University Health Board from 01/01/11

0

5

10

15

20

25

30

21 J

an 1

1

26 J

an 1

1

02 F

eb 1

1

10 F

eb 1

1

12 F

eb 1

1

15 F

eb 1

1

22 F

eb 1

1

18 M

ar

11

19 M

ar

11

Days b

etw

een

even

ts

Values Median (7.0) Lower (0.0) Upper (22.7)

Days Between Pressure Damage

– B2 Vascular Surgery

SKIN Bundle Compliance

Data collection,

feedback and testing

Many PDSAs on different

elements of the bundle

continued to achieve

process reliability Implementation and spread

throughout unit

Days between pressure damage

events

Medicines Reconciliation• Ongoing monthly data collection for all new admissions of %

patients with no medicines reconciliation within 24 hours

• Sequential days provide “virtual weeks” to highlight impact of

week-end service

Joint primary/secondary care initiative

• Medicine Use Review‟s targeted to follow up patients with

identified reconciliation issues post discharge

All-Wales prescribing intervention exercise

• To include extent and seriousness of reconciliation errors

High risk drugs - anticoagulants

• Ongoing run charts of reported INRs >5 and >8

• MSc data analysis of anticoagulant associated major bleeds

and impact of SPI2/1000 Lives (+)Methodology may be transferable to other Health Boards

High risk drugs - anticoagulants

• Root cause analysis of INRs >5 and treatment given• Majority of high INR‟s on established therapy,

• only half of “counselled” patients could recall important aspects,

• multi factorial or new/worsening disease state most common reason,

• 12% around time of initiation,

• 18% following new medication,

• advice on treatment of raised INR only followed 50% of time

• Survey of communication to primary care on discharge Root cause analysis of INRs >5 and treatment given

• Newer style form preferred

• Information received by more than one route 51%

• Fax route preferable 65%

• Information always arrives in good time 19%

• Information sometimes arrives in good time 78%

• Forms always filled in correctly 38%

• Forms sometimes filled in correctly 54%

• Obvious contact for queries 81%

• Discharge at weekends and before patient apparently stable raised as concerns

High risk drugs - Insulins

• Insulin prescription administration

chart with patient safety issues

from MSc FMEA

• “Hypo pack” introduced on wards

following national guidance –

supported by training of nursing

staff

UHB safe medication practice group

Feedback from, and input to, divisional quality and safety groups1. Manages NPSA rapid response reports– Omitted and delayed medicines

– Promoting safer use of Injectable medicines

– Safer insulin management

– Promoting safer use of lithium

– Preventing fatalities from medication loading doses

– Safer ambulatory syringe drivers

– Oxygen Prescribing

– Infusion of IV fluids and medicines in neonates

2. Local issues– Supporting medicines related patient safety in out of hospital care e.g. acute response team

– Purchasing for safety

– DVT risk assessments

HAT Risk Assessment

Successes so far

• Risk assessments are in place in most clinical areas: only

some specialised areas now outstanding e.g. spinal

• Audit tool developed to measure compliance with risk

assessment completion – tool tested using PDSA, 4 audits

have been completed to date

• Education surrounding HAT incorporated into induction for

junior Doctors

• A Clinical Champion established within the UHB, Dr Rachel

Rayment

Successes so far

• Business case presented to Board re thrombosis service: well received and awaiting outcome.

• Improved communication with GPs re thromboprophylaxis using GP newsletter

• Engagement of orthopaedics and resolution of the bleeding risk v clot risk debate, and implementation of orthopaedic risk assessments

• Development of a care pathway for extended thromboprophylaxis and patient self administration of enoxaparin and commencement of pilot of extended TP in orthopaedics

• Patient education throughout National Thrombosis Week in May 2011

Ongoing work: Successes so far

• Updating Patient Information leaflets.

• Ongoing work to update the plasma screens across UHW

• Engaging with data analysis team to calculate Hospital

Acquired Thrombosis Rate

• Developing a sticker to be used on patient drug chart

Main Challenges

• Ensuring compliance with both the risk assessment and the

audit tool

• Medical engagement with risk assessment process

Process Measures

The audit tool ask 4 main questions:

1. Was the initial Risk Assessment Completed?

2. Was the second Risk Assessment completed?

3. Was TPx recorded on the Patient‟s drug chart

4. Was the Patient deemed to be at risk of VTE?

Outcome Measures

Work continues re data collection

Process Measures: First audit results• The results from our first Audit show that further work needs to be undertaken

regarding compliance with both the audit and the risk.

• 7% return rate of Audit form

• 15% Patients received the initial Risk Assessment.

• 1% Patients received the second Risk Assessment

• Several Patients received a partial Risk Assessment.

• 64% Patients received LMWH (Thromboprophylaxis)

Process Measures: Second audit results• An increasing amount of Patients are receiving an „eyeball‟ Risk Assessment.

• Clinicians will be encouraged to use the Formal Risk Assessment tool.

• Not all areas completed the requested audit tool.

• Monitor the completion of Risk Assessments to create a link to the Risk Assessment Tool

• Necessary steps to improve our next set of results

Process Measures: Third audit results:• 40% return rate of audit (increase from previous audits)

• 27% full risk assessment completed

• 12% partial risk assessment

• 56% no risk assessment

• 66% patients prescribed LMWH

• 10% patients deemed at risk on audit form

Process Measures: Fourth audit results:• 43% return rate of audit (increase from previous audits)

• 16% full risk assessment completed


• 71% no risk assessment

• 57% patients prescribed LMWH (decrease)

• 22% patients deemed at risk on audit form

Process Measures:

Continual Good Practice in Gynaecology

Third Audit Highlights:• 90% full risk assessment


• Of this 90%, 90% LMWH, 90% weight recorded

Fourth Audit Highlights: • 100% full risk assessment

• % partial risk assessment

• Of this 100%, 90% LMWH, 100% weight recorded

Extended thromboprophylaxisSituation

• 3 month pilot undertaken of Patient self administration of enoxaparin for prevention

of Venous Thromboembolism

• Commenced in January 2011

• 48 patients undergoing hip/ knee replacement included in pilot group

• Self administration will greatly reduce District Nursing time

Background

• No guidelines or education in place to support nurses in facilitation of patient self

administration

• Pilot agreed by Nursing and Midwifery Board

Assessment

• 29 of the 48 patients in pilot group took part (patients were not suitable, out of area

or refused to take part)

• Patients were educated and assessed – on discharge:

• 39% level 3- able to self inject

• 46 level 2 –required minimal prompting

• 11 level 1- required supervision

Extended thromboprophylaxisAssessment

• Once discharged all patients received a follow up District Nurse visit

• Patient satisfaction questionnaire filled in at 6 week outpatient appointment.

• Patient feedback was positive: 93% of patients found that the assessment process

was structured and easy to understand

• 80% patients indicated they were very confident at self administering

• 67% felt that the initial district nurse visit was important

• The pilot has to date saved 130 hours of District Nursing Time.

Recommendations

• Extend pilot to included Trauma and Gynaecology

• Implement triplicate of care pathway which will improve data collection

• Present pilot feedback to Nursing and Midwifery Board

Next steps

• HAT is a continuing priority for the UHB Executive Board.

• Develop Task and Finish Groups to help embed the Risk

Assessment Tool and increase compliance

• Continue education of Junior Doctors

• Await board decision on business case for Thrombosis Nurse

• Ensure appropriate Risk Assessment Tool are in admission

booklets

Were VTE assessments completed?

30

2182

Fully Partially No

Did patients receive Pharmalogical

Thromboprohylaxis?

77

54

2

Yes No N/A

Did patients receive Mechanical

Thromboprohylaxis?

43

88

2

Yes No N/A

How many patients received

Thromboprohylaxis?

82

49

Yes No

Improving Care, Delivering Quality … · Improving Care, Delivering Quality Reducing mortality & harm in Cardiff & Vale University Health Board National Learning Session - 10th June

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